Physical Examination of the Shoulder in the Primary Care Setting 783 John M. McShane, Michael J. Graveley, and Bruce D. Hopper

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1 SPORTS MEDICINE, PART I Preface Vincent Morelli xiii Physical Examination of the Shoulder in the Primary Care Setting 783 John M. McShane, Michael J. Graveley, and Bruce D. Hopper Shoulder problems are extremely common reasons for visiting a primary care physician. To make a correct diagnosis, an appropriate physical examination must be performed. This article describes a systematic approach to the physical examination, correlating the various maneuvers and tests with the anatomy and pathology of the shoulder. The steps in this examination are: inspection, observation, palpation, manual muscle testing, and special testing. With this type of systematic approach, the physician is more likely to arrive at an accurate diagnosis. Shoulder Impingement Syndrome 789 Jeremy Henrichs and David Stone This article deals with the diagnosis and treatment of shoulder impingement syndrome. Rotator Cuff Injuries and Treatment 807 Douglas G. Browning and Maulin M. Desai Rotator cuff problems are among the most commonly encountered disorders of the shoulder, and are commonly seen by primary care physicians. Their exact mechanism for susceptibility to injury remains unclear; however, with an understanding of the shoulder s anatomy and biomechanics, we are better able to treat the insults incurred on the cuff. Early recognition, proper treatment, and appropriate follow-up may expedite healing and prevent the occurrence of further injury or complications. VOLUME 31 Æ NUMBER 4 Æ DECEMBER 2004 vii

2 Superior Labrum, Anterior Posterior Lesions and Biceps Injuries: Diagnostic and Treatment Considerations 831 Marc I. Harwood and Christina T. Smith Injuries to the glenoid labrum and biceps tendon are common in the active population. Because of the close anatomic relationship between these two structures, the authors discuss disorders of these structures together. Diagnostic considerations, including physical examination and imaging findings, are discussed, in addition to management options for each of these problems. The Acromioclavicular Joint 857 Phyllis Montellese and Timothy Dancy Multiple common conditions affecting the acromioclavicular (AC) joint are appropriate for primary care physicians to treat. This article reviews the diagnosis and management of AC joint separation, osteoarthritis, and distal clavicle osteolysis. The goal is to provide the primary care physician enough information to confidently diagnose and treat these common conditions. Shoulder Instability 867 Rob Johnson, Sarah Lehnert, Brad Moser, and Shane Juenemann Shoulder instability can result from acute injury or repetitive overhead activity. Once the injury is identified, the initial course of treatment is aggressive rehabilitation. Structural injuries can occur but may not be clinically significant. Should a thorough scapular stabilization and rotator cuff strengthening program fail, consultation with an orthopedic surgeon to consider further imaging or possible intervention is appropriate. As the physician s study of approaches to the first-time dislocator continues, they will be better informed of reasonable options to offer the athlete. Physical Examination of the Knee 887 Joseph E. Allen and Kenneth S. Taylor Patients with knee pain often present for initial evaluation to their primary care physician. Regardless of whether the assessment involves an acute traumatic injury or a chronic process, the clinician should have the ability to obtain a detailed history, perform a thorough musculoskeletal examination, and pursue proper imaging and laboratory testing to make an accurate diagnosis before the initiation of a therapeutic treatment regimen. Patellar Tendonitis and Patellar Dislocations 909 Vincent Morelli and Robert H. Rowe Common sports injuries, such as patellar tendonitis and patellar dislocation, can be treated either surgically or with rehabilitation viii

3 and physical therapy. Most patients with patellar tendonitis will respond well to conservative measures; however, some recalcitrant cases will require surgical intervention. To date, the literature is not able objectively to identify the patients best suited to surgery. Likewise, in the case of patellar dislocations, it is still unclear which patients respond best to conservative therapy and which respond best to surgical treatment, although evidence continues to accumulate. A practical approach to this problem can be deduced from the available evidence, but more well-designed clinical trials are needed for the establishment of definitive treatment protocols. Anterior and Posterior Cruciate Ligament Injuries 925 Jeffrey R. Brown and Thomas H. Trojian Knee injury and knee pain are common complaints in the primary care setting, accounting for approximately one-third of musculoskeletal complaints. Anterior cruciate and posterior cruciate ligament (ACL and PCL) injuries are common causes of knee pain. Therefore, it is important for primary care physicians to be skilled in the diagnosis and initial management of these injuries. By understanding the history, mechanism of injury, physical examination maneuvers, and imaging modalities related to ACL and PCL injuries, primary care physicians can prepare themselves to make an accurate diagnosis. Likewise, they can counsel the patient on the available treatments, initiate conservative treatment (if appropriate), and facilitate an effective referral to a primary care sports medicine physician or orthopedic surgeon. Medial and Lateral Collateral Injuries: Prognosis and Treatment 957 James D. Quarles and Robert G. Hosey This article presents a comprehensive review of medial and lateral knee ligament injuries. It reviews the basic anatomy, physical examination, imaging techniques, and current treatment of medial and lateral knee injuries. It includes a step-by-step guide to proper physical examination of the knee as well as MRI images. Current treatment of medial and lateral knee injuries is extensively reviewed to aid the primary care physician in diagnosis and provision of care. Patellofemoral Pain Syndrome: Evaluation and Treatment 977 Cynthia LaBella Patellofemoral pain is the most common knee problem encountered by primary care physicians. A complete understanding of the etiology, pathophysiology, and optimal treatment of patellofemoral pain syndrome is still lacking; hence, it can be a source of frustration for both the patient and the physician. The purpose of this article is to describe the current understanding of the etiology and pathophysiology of patellofemoral pain syndrome, highlight ix

4 the important points in the clinical evaluation of patients who have anterior knee pain, and describe the evidence to support the commonly prescribed treatments. Soft-Tissue Injuries of the Lower Extremity 1005 James L. Glazer and Robert G. Hosey This article contains information about the most common softtissue injuries affecting the lower extremity. Each anatomic region is covered separately, with an emphasis on anatomy and physical examination for such conditions as hamstring strains, medial tibial stress syndrome, and plantar fasciitis. The most recent literature regarding both operative and nonoperative treatment approaches to each condition is reviewed. The Ankle Examination 1025 Kimberly G. Harmon Ankle injuries are among the most common musculoskeletal complaints a physician will see. A thorough understanding of the bony, ligamentous, and musculotendinous anatomy and an appreciation of the biomechanics of the ankle and mechanisms of injury are important to the accurate assessment of ankle injuries. Achilles Tendonopathy and Tendon Rupture: Conservative Versus Surgical Management 1039 Vincent Morelli and Ernest James Injuries to the Achilles tendon are common in primary care. Insertional tendonitis, retrocalcaneal bursitis, and paratenonitis are acute injuries usually treated conservatively with rest, ice, antiinflammatory measures, and physical rehabilitation. Causative factors such as improper training or biomechanical abnormalities must be corrected to prevent reoccurrence. Achilles tendinosis is a chronic condition that does not always cause clinical symptoms. When symptoms occur, they are thought to be due to microtrauma or progressive failure resulting in inflammation. Again, conservative treatment usually relieves symptoms, but treatment may be prolonged. Surgical treatment may occasionally be recommended. With rupture of the Achilles, there exists some controversy regarding the advantage of conservative versus surgical management. Treatment should be based on individual patient considerations and expectations. Ankle Problems Masquerading as Sprains 1055 Kim Edward LeBlanc The most common ankle injury is a ligamentous sprain, usually involving the lateral side. This is usually treated very successfully with conservative management. Those patients who have continx

5 ued complaints despite such management should be suspected of having something more than a simple sprain. The diagnostic entities discussed herein should always be part of the differential diagnosis of a sprained ankle, so that when one of these injuries is initially missed, the examining physician will be able to re-examine and eventually diagnose and treat these injuries properly. They should be managed appropriately as soon as possible for the best outcome. Needless delays should be avoided. Cumulative Index xi